Intensified empirical elimination diet is the current gold standard for a dietary approach in patients with eosinophilic esophagitis. Milk, followed by wheat, egg and soybean, are the most frequent foods that trigger eosinophilic esophagitis in pediatric and adult patients. But what dietary treatment for eosinophilic esophagitis?
What is eosinophilic esophagitis?
Eosinophilic esophagitis is a chronic disease induced by allergic antigen, limited to the esophagus, characterized by symptoms of esophageal dysfunction and predominantly eosinophilic inflammation. It is considered a disease triggered mainly by food antigens. Food allergy tests available in clinical practice (IgE-based blood tests against food, atopic contact tests, skin tests) do not accurately predict triggering foods that cause eosinophilic esophagitis in children or adults. Since, it is an allergic condition not mediated by IgE antibodies.
Intensified empirical elimination diet
Currently, dietary treatment for eosinophilic esophagitis consists of the elimination of the most common foods that trigger the condition. In 2006, a new empirical diet eliminating six groups of foods (milk, wheat, egg, soy/legumes, nuts, fish/seafood) that represented the majority of local lye reactions led to complete histological remission in three out of four pediatric patients with eosinophilic esophagitis. After the validation of these initial pediatric results and in two large studies in adults, the restriction of these 6 groups became the standard for dietary therapy in clinical practice. However, fish/seafood and nuts played an insignificant role as causatory foods after reintroduction.
Therefore, after these discoveries, a new diet of elimination of four foods was developed only eliminating the four most common food groups (milk, wheat, egg and soy). Interestingly, milk was the only food that caused up to 55% of patients. Therefore, studies have proven that about half of the responders actually had one or two food triggers (usually milk and wheat), so they could have achieved histological remission starting with a simpler dietary scheme: a two-food elimination diet only.
Thus, a progressive empirical elimination diet, from one or two food groups, is the current gold standard for a dietary approach in children and adult patients with eosinophilic esophagitis. Therefore, avoiding triggering foods in a very restricted way can be problematic in the long run, even unfeasible with various triggering foods.
Clinical practice
A progressive empirical elimination diet is recommended for dietary therapy, with milk and wheat restriction being the most common. In case of non-remission, egg and soy restriction may also be taken into account. The exemption from contact with certain foods should be carefully discussed with patients and parents and advised by nutritionists. Malnutrition is not common in patients with eosinophilic esophagitis and is probably related to concomitant ige-mediated and non-IgE-mediated comorbidities.
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Article: Eosinophilic esophagitis – Molina-Infante J. Nutritional and Psychological Considerations for Dietary Therapy in Eosinophilic Esophagitis. Nutrients. 2022; 14(8):1588. https://doi.org/10.3390/nu14081588
